Medical Homes in Illinois
 This page is designed to keep you informed about events and activities happening in Illinois that will help improve access to medical homes for children with special health care needs (CSHCN).

Medical Home Initiatives
This section provides information on state medical home initiatives/programs. States that are a part of the mentorship network will have a "Promise to the State" which outlines how they will achieve ensuring that all children have a medical home by 2010. This is based on the Healthy People 2010 goals which is a 10 year action plan to achieve and measure success for all CSHCN.

Illinois Medical Home Contact:

Name: Rita Klemm, MSW
Contact: Phone: 217-558-2340 |Fax: 217-558-0773 | Email: dscc@uic.edu
State Team: Roster

Announcements:

newPress Release on the latest Illinois Medical Home Projects

newNew Video about Illinois Medicaid Program Highlights Medical Home
The Illinois Family Physicians put together a video for physician/practice outreach on Medicaid that highlights the Medical Home.

Updates from the Illinois Medical Home Team Adobe Acrobat

  • History of Illinois Medical Home efforts

  • Title V Facilitation for Medical Home Quality Improvement Teams: As the Title V agency in  Illinois, the UIC Division of Specialized Care for Children (DSCC) elected to support early medical home endeavors by providing trained Facilitators to help primary care practices establish a medical home quality improvement team and begin making changes to improve care delivery.  DSCC Facilitators have been working with primary care practices since 2002 and many have made simple but significant strides in providing comprehensive, coordinated, accessible, culturally competent, continuous care for families and children with special health care needs.  DSCC staff who serve as Quality Improvement team facilitators have developed a Facilitator's Guide to help practices who want to begin the quality improvement process to providing a medical home.
  • The following is a sample list of Title V facilitated Medical Home QI teams in Illinois and a link to a brief narrative of each team’s improvement efforts:
    • North Arlington Pediatrics (large suburban private group practice) – started 2005 (link to NAPQIActivitiesSummary.pdf)
    • Pediatrics Center (rural solo practice) – started 2004 (link to PediatricsCenterQIActivities1208.pdf)
    • Crusader Clinic (FQHC) – started 2006 (link to CrusaderClinicQIActivitiesSummary.pdf)
    • Premier Kids Program (NICU follow-up clinic at a children’s specialty hospital) – started 2006 (link to PremierKidsProgramQIActivitiesSummary .pdf)
  • Illinois Medical Home Project Phase II Results and Project Update, October 2008 - Report
    (KS/JE)
  • Summary Progress Report for Year 4, July 2007 to June 2008 -PowerPoint

  • When It Comes to Special-needs Kids, There’s No Place Like “Home”: Pilot Program Takes a New Approach to Pediatric Care - Article

  • IMHP ANNUAL NEWSLETTER: "Medical Homes: Spreading Innovative Practices"
    March 2007
    September 2005

  • Medical Home Project Learning Session Videos:

    • Medical Home Project Learning Session III, December 2007:  Presentations (video-taped*)
      *The free Windows Media Player is necessary to view the presentations at the following links:
  • Medical Home Project Learning Session II, March 10, 2007: Presentations (video-taped)
    *Windows Media Player is necessary to view the presentations at the following link: http://video.google.com/videosearch?q=%22medical+home%22

MCHB Medical Home Grant: Illinois Medical Home Project Abstract share
Contact: Kathy Sanabria, MBA, PMP Phone: 312-733-2850 | Email: ksanabria@illinoisaap.net
Project Period: July 1, 2004 to June 30, 2008
Purpose: The IMHP supports development of community-based medical homes for CYSHCN by informing primary care providers about the medical home model; providing access to quality improvement (QI) processes involving partnerships with parents, linkages to community resources, and reimbursement; facilitating QI Teams at practices; and sponsoring Leadership Forums to develop statewide action plans. For more information on the Illinois Medical Home Project please visit their website at www.illinoisaap.org/medicalhome.htm.

A Medical Home Primer for Community Pediatricians and Family Physicians
This monograph offers busy primary care providers a menu of suggestions that can be incorporated into their practice to improve the quality of health care provided to patients and families through a medical home.  These suggestions will provide a naturally evolving approach to building a medical home, but, providers need only consider those options that are most appropriate for their practice setting.  An initial assessment should help guide you through the menu options to determine how to proceed.  Many suggested changes are simple to adopt and most are not costly.  This primer has been reviewed and accepted for up to 2 Prescribed Credit Hours by the Illinois Academy of Family Physicians. IAFP Prescribed Credit is accepted by the AMA as equivalent to AMA PRA Category 1 Credit for the AMA Physician's Recognition Award (PRA).

Primary care physicians who become approved DSCC medical home providers may be reimbursed for the care coordination activities provided for eligible children with special health care needs. Physicians interested in becoming a medical home provider need to successfully complete the CME activity. For additional information about becoming a DSCC medical home provider, contact DSCC for more information.

Medical Home Information for Families
"What Families Need to Know about a Medical Home" has been developed to explain the Medical Home Model for families and children with special health care needs. It explains the family-professional partnership and how it relates to accessing quality health care. The primer goes on to explain how families can become proactively involved in Quality Improvement Teams in their primary care provider's practice. There are links to the AAP web site describing what others states are doing to promote Medical Home, a downloadable Parent-Partner Guide, Power Point presentations, and information about the Illinois Title V CSHCN Program.

Medical Home Physician Reimbursement Brochure
DSCC recognizes that serving children with special health needs is often more complex and time consuming. Medical Home Physicians may be reimbursed when the level of decision-making or planning complexity requires more physician time. Reimbursable services may include telephone consultations with specialists, care plan oversight and certain care coordination activities not otherwise covered by third party payers. More specific information is available in the DSCC Reimbursement Guidelines for Medical Home Services share brochure. If you have any questions or would like more information about becoming a Medical Home Physician, please contact DSCC.

Pediatric Specialists Available for Consultation to Assist Primary Care Physicians Managing Care for CSHCN
A statewide network of pediatric specialists who will provide telephone consultation to community primary care physicians is available. For physicians with limited experience in treatment planning for medically complex children, the consultants are available to provide consultation in the development and management of care for CSHCN. Reimbursement for consultation services with these specialists may be available for DSCC approved medical home providers. Contact DSCC for more information about becoming a DSCC approved medical home provider.

Illinois Statewide Medical Home Implementation Plan: 2001 Promise to the State share
Read about the Illinois Statewide Medical Home Implementation Plan. This document is available in PDF and requires the Adobe Reader to view and print the brochure. The Reader is available free from the Adobe web site.

Families Assisting in the Development of the Medical Home Implementation Plan
Members of the DSCC Family Advisory Council, which is comprised of families representing each of the agency's thirteen service regions throughout Illinois, have been engaged in the development of the medical home concept. Members participated in the development of medical home informational brochures for distribution to families and physicians.

Related Grant Initiatives
This section provides information on current state grants that are working on medical home initiatives. This iincludes the grant abstract as well as key contacts for the grant.

newThe Region 4 Collaborative (IL, IN, KY, MI, MN, OH, & WI) awarded a Medical Home/Genetics Visting Professorship Pilot Program

Medical Home/Genetics Visiting Professorship Pilot Program

The American Academy of Pediatrics National Center for Medical Home Initiatives for Children with Special Needs and the American College of Medical Genetics' National Coordinating Center for the Regional Genetics and Newborn Screening Service Collaboratives (NCC) in partnership with the ACMG and MCHB recently developed a pilot visiting professorship program. This program focuses on the specific topic areas of genetics and medical home and also establishing linkages between Regional Genetics and Newborn Screening Services Collaboratives (RCs) and AAP Chapters.

Universal Newborn Hearing Screening and Intervention: Reducing Loss to Follow-up after Failure to Pass Newborn Hearing Screening   (April 2008 – March 2011)

This grant will address Illinois’ challenges and improve short and long term outcomes for infants with hearing loss and their families. The goal of Illinois’ UNHS Program is to identify infants needing diagnosis by 1 month, achieve diagnosis by three months of age, and link those infants with hearing loss to treatment and intervention by six months of age.  Activities such as technical assistance data monitoring, and inter-agency collaboration will continue and will support the use of the Plan-Do-Study-Act quality improvement activities which will be the primary focus of the grant.   The quality improvement activities will focus on strengthening the links between newborn hearing screening, definitive diagnosis, early interventions, and connection to a Medical Home. 

IMPACC Collaborative: Improving Access to Community Care for Individuals with ASD and DD (3 year grant announced Sept 2008)

The current proposal will enhance service capacity in Illinois for its population of persons with ASD and DD via provision of three regional Health Service Facilitators and a Financing Specialist, charged with expanding and strengthening linkages with The Autism Program (TAP) Service Network, comprised of 30 agencies and universities whose missions include system development and evidence-based service provision. Access to the medical home model is emphasized in grant-initiated activities.  

Educational Initiatives
This section provides information on training initiatives on the medical home. Some states will discuss their outreach projects in relation to physicians, families, and the community.

Educational Outreach Includes Medical Grand Rounds and CATCH Meetings
Efforts to provide primary care providers with information on the medical home model and the tools needed to introduce the process within their medical practices are underway. DSCC provides presentations on the medical home model at local CATCH (Community Access to Child Health) meetings and at medical grand rounds upon request. These opportunities provide physicians and other interested health care providers with information about the state Title V program (DSCC), introduction to the medical home model, and a brief introduction to the Medical Home Index and Medical Home Family Index.

Medical practices interested in arranging on-site presentations and anyone interested in further information can contact the DSCC medical home technical assistance team, by phone (1-800-322-3722) or e-mail at dscc@uic.edu. Physician Outreach
Physicians interested in learning more about the benefits of providing a medical home for children with special health needs are urged to contact DSCC and arrange a free on-site inservice on the medical home model. With each medical practice inservice, 1-2 hours of free CME credit will be given for successful completion of the CME activity. The DSCC medical home team will provides 60-minute presentations for physicians and office staff as well as copies of the Medical Home Primer. Presentations can be arranged at your office upon request. To contact the medical home technical assistance team at DSCC, call 1-800-322-3722 or e-mail the team at dscc@uic.edu.

Partners in the State
Many organizations and individuals have been actively involved and instrumental in the medical home initiatives undertaken in Illinois. The following partners are acknowledged for their dedication and commitment to families and children with special health care needs:

UIC-Division of Specialized Care for Children
Administered by the University of Illinois at Chicago, the Division of Specialized Care for Children (DSCC) is the Illinois Title V agency that provides care coordination for families and children with special health care needs. DSCC has been one of Illinois' lead agencies in developing and implementing the medical home model in Illinois. To find out more information, visit the DSCC website.

Title V Block Grant to States
Title V of the Social Security Act is one of the largest Federal block grant programs. It leads the nation in ensuring the health of all mothers, infants, children, adolescents, and children with special health care needs (CSHCN). Title V is administered by the Maternal and Child Health Bureau (MCHB) as part of the Health Resources and Services Administration, U.S. Department of Health and Human Services.

Title V and Children with Special Health Care Needs
MCHB Objective: Support development and implementation of comprehensive, culturally competent, coordinated systems of care for the estimated 18 million U.S. children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.

MCH Contact:
Dr. Myrtis Sullivan, M.D., M.P.H.
Associate Director for Family Health
Address: 1112 S. Wabash - 3rd Floor
Chicago, IL 60605
Phone: 312-793-4605 | Fax: 312-793-4666
Email: Myrtis.Sullivan@illinois.gov
Internet site: www.dhs.state.il.us/chp/

Early Hearing Detection & Intervention (EHDI) Contact(s):
State EHDI programs promote universal newborn hearing screening, develop effective tracking and follow-up as a part of the public health system, promote appropriate and timely diagnosis of the hearing loss, prompt enrollment in appropriate Early Intervention, link newborns to a medical home and strive to eliminate geographic and financial barriers to service access.

Name: Gail Tanner, MS CCC-A
Contact: Phone: 217 782-4733 - Fax: 217-557-5324
Email: gtanner@idph.state.il.us

Early Intervention/Part C Coordinator:
The Program for Infants and Toddlers with Disabilities (Part C of IDEA) is a federal grant program that assists states in operating a comprehensive statewide program of early intervention services for infants and toddlers with disabilities, ages birth through age 2 years, and their families.

Name: Janet Gully, Chief
Contact: Phone: (217) 782-1981 | Fax: (217) 524-6248
Email: dhsvr50@dhs.state.il.us
Website: www.state.il.us/agency/dhs/eisnp.html

Section 619/ Preschool Grants Program of the Individuals with Disabilities Education Act (IDEA). This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities:

Name: Pam Reising-Rechner, Principal Consultant
Contact: Phone: (217) 524-4835 | Fax: (217) 785-7849
Email: preising@isbe.net
Website: www.isbe.net/earlychi/Default.htm

Illinois State Interagency Coordinating Council on Early Intervention (IICEI) Chairs:
The ICC advises appropriate agencies on the unmet needs in early childhood special education and early intervention programs for children with disabilities, assists in the development and implementation of policies that constitute a statewide system, and assists all appropriate agencies in achieving full participation, coordination, and cooperation for implementation of statewide system.

Name: Beatrice Nichols, IICEI Chairperson/ Head Start Representative 
Contact: Phone: 312/743-1635 | Fax: 312/743-0400
Email:  beatrice.nichols@cityofchicago.org

Illinois Interagency Coordinating Council (ICC) on Transition
The Illinois Interagency Coordinating Council (ICC) was established in 1990 by the Interagency Coordinating Council Act, 20 ILCS 3970 to facilitate collaboration among state agencies and improve outcomes for youth with disabilities. The ICC is charged with gathering and coordinating data on services for transition-age youth with disabilities; providing information, consultation, and technical assistance to state and local stakeholders; assisting state and local stakeholders in establishing interagency transition agreements; conducting an annual statewide evaluation of student transition outcomes and needs; and, providing in-service training to consumers in developing and improving awareness of transition services.

Name: Marva Campbell-Pruitt and Elizabeth Hanselman, co-chairs
Website: http://www.isbe.state.il.us/iicc/

 

Resources/Documents
Continuing Medical Education Module available on the Medical Home Model
The Medical Home Primer has been developed to introduce primary care providers to the concept of a medical home and define how the Division of Specialized Care for Children (DSCC) will integrate this concept within the agency's care coordination activities. The primer addresses reimbursement strategies for providers managing children with special health care needs. This primer has been reviewed and accepted for up to 2 Prescribed Credit Hours by the Illinois Academy of Family Physicians. IAFP Prescribed Credit is accepted by the AMA as equivalent to AMA PRA Category 1 Credit for the AMA Physician's Recognition Award (PRA). When applying for the AMA PRA, Prescribed Credit Hours earned must be reported as Prescribed Hours, not as Category 1. Completion of the CME activity is part of the process for becoming a DSCC approved medical home provider.

Primary care physicians who become approved DSCC medical home providers may be reimbursed for the care coordination activities provided for eligible children with special health care needs. Physicians interested in becoming a medical home provider need to successfully complete the CME activity. For additional information about becoming a DSCC medical home provider, contact DSCC for more information.

Medical Home Brochures:

Family Brochure: What is a Medical Home and What does it Mean for You and Your Child?
This brochure was developed to help families of CSHCN understand how they can work with their primary health care provider to establish a Medical Home.  It provides a definition of medical home along with a description of the elements of care within a medical home including accessible, family-centered, comprehensive, and coordinated care.  The family brochure is available from the DSCC web site in PDF format - you will need the Adobe Acrobat Reader to view and print the brochure. The Reader is available free from the Adobe web site.

Physician Brochure:
What Does It Mean to Have a Medical Home Relationship with Families
This brochure for providers explains the definition of the medical home, the family-professional partnership, medical home resources, and the requirements for becoming a DSCC approved provider. The physician brochure share is available from the DSCC web site in PDF format - you will need the Adobe Acrobat Reader to view and print the brochure. The Reader is available free from the Adobe web site.

Creating a Medical Home – The Foundation of Primary Care
The University of Illinois at Chicago, UIC, Division of Specialized Care for Children, (DSCC) is the Title V program in Illinois serving children with special health care needs from birth to age 21 years.  The DSCC website, has information and resources to inform both professionals and families about providing and having a Medical Home.  To find out more go to http://internet.dscc.uic.edu/medhome/mhintro.asp

Medical Home Posters
The Illinois Medical Home Project has developed Medical Home poster templates, in both English and Spanish, for practices to use. Here are some samples:
                Sample Poster 1 - English                                Sample Poster 1 - Spanish
                Sample Poster 2 - English                                Sample Poster 2 - Spanish
Contact DSCC for assistance in customizing and creating posters for your office. Our staff will work with you to design free Medical Home posters that meet your specific needs and can be printed at local printing facilities. (Contact information: http://internet.dscc.uic.edu/dsccroot/info_request.asp )

Transition to Adulthood: web-based resources
Planning for the transition from pediatric doctors to adult doctors, moving from school to work, and achieving the highest level of independent living can be exciting and challenging. It is never too early to begin thinking about and preparing for your child's future. The Division of Specialized Care for Children (DSCC) has a comprehensive Transition section on their web site. These materials can help guide families as they navigate life's transitions and are available at: http://internet.dscc.uic.edu/dsccroot/parents/transition.asp

Teen Transition Facts for Health Professionals Brochureshare
The Illinois American Academy of Pediatrics developed this brochure to help prepare health professionals for transitioning their patients to adulthood.

State Waiver Information: http://www.hfs.illinois.gov/hcbswaivers/
Waivers are the result of a process that allows state Medicaid agencies to apply for and receive permission from Centers for Medicare and Medicaid Services (CMS) to provide services not otherwise covered by Medicaid and/or to do so in ways not described by the Social Security Act. Most Medicaid managed care programs require Waivers. The Waivers, which can differ greatly, are known by their numbers (1115, 1915c), or as home-and community-based, or as Katie Beckett Waivers.

Screening Initiatives
This section provides information on surveillance and screening initiatives in the state.

State Newborn Screening & Genetics Programs:web site: http://www.idph.state.il.us/HealthWellness/genetics.htm
the Illinois Department of Public Health (IDPH) Genetics Program provides access to appropriate genetic services for any family with concerns about an inherited condition, and to increase awareness of services provided by the program among health care providers and consumers. Genetic services are available to families or persons of any age residing in Illinois, who may have a family history of, or concern about a medical condition with a genetic basis. Referrals can be made by physicians, other health care providers, schools, self referrals, or other means.

Illinois Newborn Hearing Screening Program:
web site: http://illinoissoundbeginnings.org/
Every year in Illinois, as many as 500 babies are born with hearing loss.  The Newborn Hearing Screening Program, required by the Hearing Screening for Newborns Act (410 ILCS 213), identifies infants born with congenital hearing loss and ensures they are provided with amplification devices and therapy by six months of age. The Program is collaboration between the Illinois Departments of Human Services (IDHS), Public Health (IDPH), and the University of Illinois at Chicago's Division of Specialized Care for Children (DSCC). The Program services include training for providers on screening and referral; parent information; diagnostic evaluation; and follow-up.

Newborns are screened before being sent home and the screening results are sent to IDPH. When screening indicates that the infant may not have normal hearing, the infant's parents and physician are notified so that the infant can be referred for diagnostic testing. These testing results are also reported to IDPH. Infants with diagnosed hearing loss are referred to DSCC and the Part C (Early Intervention) program for therapeutic services.

Illinois Early Autism Detection and Referral Program
The Illinois Chapter of the American Academy of Pediatrics (ICAAP) has won the Award of Excellence in the 2005 Associations Advance America (AAA) Awards programs, a national competition sponsored by the American Society of Association Executives (ASAE), Washington, DC.

ICAAP received the award for its physician education program titled, Screening Tools and Education for Pediatric Providers 2 (STEPPs 2): Early Autism Detection and Referral, which was developed by Illinois pediatricians. Autism has gained a great deal of national attention in recent years. The Centers for Disease Control estimates that as many as 1 in 166 children may be affected by an autism spectrum disorder (ASD). Early detection and referral by physicians is crucial to helping children get the best start they can.

STEPPs 2 is now in the running to receive a Summit Award, ASAE’s top recognition for association programs, to be presented in ceremonies at ASAE’s 6th Annual Summit Awards Dinner in September 2005 in Washington, DC. STEPPs 2 is funded by The Autism Project (TAP) of the Illinois Department of Human Services. TAP’s goal is to promote an overall systems change in Illinois for those with ASD. One of the ways in which they do this is to raise awareness of autism among primary care medical professionals, in order to help children with autism get the early diagnosis and intervention services they need. The STEPPs 2 program has made possible by offering providers an overview of ASD, including definitions and information about recognizing early signs of autism. The educational program also discusses common misconceptions about the causes and stereotypes of autism, as well as how to refer children who show signs of autism to the Early Intervention system, the Special Education system, and to specialists. ICAAP also strives to help the office staff become familiar with the team approach to diagnosis and the importance of evidence-based treatment of autistic spectrum disorders. Practicing pediatricians and experts in the field serve as speakers for the program, which will have been presented nearly 60 times in private practices, clinics, and hospitals by June 2005. For more information on the STEPPs 2 program, contact Sarah Baur, project director, at sbaur@illinoisaap.net or 312-733-1929.

Assuring Better Health and Child Development (ABCD) Program: Website: http://www.nashp.org/_docdisp_page.cfm?LID=BB138571-949F-4AFB-8AD4813752870C0D
The ABCD II Initiative, launched in 2003, is designed to assist states in building the capacity of Medicaid programs to deliver care that supports children’s healthy mental development.

Illinois was chosen as one of five states to join the National Academy for State Healthy Policy’s (NASHP’s) Assuring Better Child Heath and Development II (ABCD II) initiative. Other states involved in the initiative are California, Iowa, Minnesota and Utah. In Illinois, the project is called “Healthy Beginnings.” The Illinois Department of Healthcare and Family Services (IDHFS, formerly the Illinois Department of Public Aid) is the lead agency for Healthy Beginnings and is working in partnership with many organizations which are focused on improving child health and development, including the Illinois Chapter of the American Academy of Pediatrics (ICAAP), the Illinois Academy of Family Physicians (IAFP), and the Ounce of Prevention Fund.

Enhancing Developmentally Oriented Primary Care: www.edopc.org
The Illinois Chapter of the American Academy of Pediatrics (ICAAP), the Advocate Health Care Healthy Steps Program, the Illinois Academy of Family Physicians (IAFP), and the Ounce of Prevention Fund have partnered on an initiative to define developmentally-oriented primary care and identify needs for Illinois pediatric care providers in terms of training, technical assistance, and community support. The partnership focuses on using the Healthy Steps model and other programs to develop a range of strategies that practices can implement to most effectively provide developmentally-oriented primary care. Not every medical site will be able to implement all the recommended Healthy Steps components, and each practice faces unique challenges in terms of its patient population, staff strengths, and other factors. One goal of the project is to develop a training and technical assistance program that meets the needs of the diverse group of health professionals providing care to the children of Illinois. An advocacy component will work with state systems and legislation to create the supports necessary for providers to better address child development issues.

For more information, please contact: info@edopc.org, 1-888-270-0558, or
Sarah Baur, ICAAP Developmental Projects Director: sbaur@illinoisaap.net

Autism Task Force Report
Illinois has undertaken several initiatives in the last eight years to address the impact of ASD. The Illinois General Assembly commissioned The Autism Program (TAP) which addresses the needs of ASD-challenged children in the areas of screening, identification, diagnosis, programs and services, workforce development, and research. Equally important has been the Illinois State Board of Education’s (ISBE) sponsorship of the Illinois Autism Technical Assistance and Training program, which provides professional development and training to local school districts and special education cooperatives. ISBE has also sponsored Giant Steps, a school with a professional best practices curriculum for ASD challenged children. Additionally, DHS has sponsored the Early Intervention Program (EI), which provides services to children birth to three years of age. http://www.dhs.state.il.us/page.aspx?item=35776

State Resources on the Internet

Note: The information provided on the state pages was submitted by the state medical home teams.As this is not an exhaustive list, please let us know if you have additions for your state resource page. You can contact us at: medical home@aap.org.

Last Updated March 25, 2009